Innovations in Health Equity and Health Philanthropy

Grantmakers In Health (GIH)
is pleased to publish this supplement
to Stanford Social
Innovation Review on innovations
in health equity, and we thank the
Aetna Foundation for sponsoring it. GIH is
a philanthropic affinity organization that informs
and advises health foundations, corporate
giving programs, and other funders,
and provides opportunities for them to
share knowledge and experiences. We are a
voice for health philanthropy, and through
our programming we advance the field.

This special supplement examines the organizations and programs that are addressing social inequalities in housing, transportation, work, and other parts of society that create disparate health outcomes.

Health equity is an area of intense focus
for philanthropy, fueled by a sense of urgency
about the need to reverse long-standing
destructive trends. It is an area in which
health philanthropy has shown consistent
leadership in support of innovative work.
Our goal in this supplement is to lift up new
voices and approaches in health equity and
to highlight the work of funders and community
organizations that use health equity
as a lens for grantmaking and partnerships.
Although it was impossible to include profiles
of all the good work occurring in communities
across the country, we did our best
to select a cross-section of programs that
are concerned with some of this nation’s
most vulnerable populations, such as youth,
LGBT people, low-income communities,
immigrants, and people of color.

The leading edge of health equity work
illustrated here encompasses a wide range of
strategies. Settings include LGBT community
centers, racially and ethnically diverse
urban communities, and rural Indian country.
Frameworks include promoting health
equity through organizing and advocacy, grantmaking, research and data collection,
regional and cross-sectoral collaboration,
and community engagement. Many aspire to
change policy in order to achieve sustained
systems-level change. Consistently, there is
a focus on community involvement, which
is very different from the perspective of the
traditional health-care system.

The work spotlighted in this supplement
is energetic and exciting. Progress
made from these various strategies will
inform our understanding of what works
while also—ideally—moving us closer to the
goal of improved health for all.

The Quest for Health Equity

The quest for health equity has its roots in
more than a century of data showing that
morbidity and mortality rates for poor
Americans and people of color are significantly
worse than those for the white mainstream.
Even in the 19th century, the lack of
health equity in the United States was a subject
of concern for advocates, scholars, and
health professionals. For example, in 1899
sociologist W. E. B. DuBois noted in his book
The Philadelphia Negro that “[there] is a much
higher death rate at present among Negroes
than among whites: this is one measure of
the difference in their social advancement.”

In 1914, Booker T. Washington commented
publicly on the high rate of preventable
death among blacks, and in 1915
he organized National Negro Health Week,
hoping to generate broad support for improving
black health. Black public health
leaders sustained this effort by continuing
to promote National Negro Health Week
for several more decades. In the meantime,
trends in black and white health changed
little, with large differences between the
two groups in life expectancy, chronic disease
prevalence, and causes of death.

In 1985, the federal government accomplished
Booker T. Washington’s then-70-year-old goal of bringing racial health
disparities to national attention with
the publication of the landmark Heckler
Report, or “Report of the Secretary’s Task
Force on Black and Minority Health.” The
report’s finding—“a sad and significant fact
[is the] continuing disparity in the burden
of death and illness experienced by Blacks
and other minority Americans as compared
with our nation’s population as a whole”—began to galvanize action.

Since 1985, the United States has made
some progress in reducing health disparities,
but it is far from enough. In fact, the federal
Agency for Healthcare Research and Quality’s
most recent “National Healthcare Disparities
Report, 2014” rated national progress in reducing
disparities in health care as “poor.” It
concluded that people of color and people in
poverty had worsening quality and access on
many disparity measures, and that there had
been no significant change over time. In addition,
the report found that whereas disparities
are decreasing in a few areas, such as the number
of deaths from HIV, they are continuing to
increase in others, such as cancer screening
and maternal and child health. The Affordable
Care Act (ACA) promises to expand the number
of Americans eligible for these and other
preventive health services, but it is not a given
that health disparities will decrease as a result.

Health Equity and the Social
Determinants of Health

Research has consistently shown that race
and socioeconomic status are important
causes of health disparities. Simply put,
disadvantaged social groups systematically
experience worse health or greater health
risks than more advantaged social groups.
From birth to death, race and class have an effect on rates of disease risk, exposure to
environmental hazards and socioeconomic
stressors, and access to health necessities
such as healthy food and safe housing.

The concept of the social determinants
of health, introduced by the World Health
Organization (WHO) about a decade ago,
has been an important tool for explaining
how the social and economic structures
that shape how people live also affect their
health. WHO’s determinants cover a broad
spectrum of social, economic, and environmental
factors. Included among them are
access to health care and education; the distribution
of power, income, and goods and
services in a community; and other conditions
at work, at home, in neighborhoods,
and in the surrounding environment.

Access to high-quality health services
is just one of several contributors to good
health status. Once thought to be the key to
good health, access is now understood to have
about half the influence of education, employment,
and other socioeconomic factors. (See
“Social Determinants of Health” below.)

Health funders’ adoption of the social
determinants approach has required them
to think differently about how they want to
target their grantmaking in order to support
healthy people and communities. The transition
has occurred gradually. In the past, many
philanthropic efforts to reduce health inequalities
focused on individuals. There was
an emphasis on primary prevention (such as
community health education and screening),
improvements in the delivery of health care,
and use of data to track trends and outcomes.

With growing evidence of the social determinants
of health, health funders began
to focus their attention on “upstream” strategies—for example, improving housing or
increasing access to education—alongside
continued “downstream” work to improve
health-care services. Interest in issues like access
to healthy food, toxic exposure and other
environmental issues, early childhood education,
and investing in communities has grown.

Making Progress on
Health Equity

Health philanthropy offers several promising
examples of progress in achieving
health equity. Admittedly, the problem is
enormous, and even successful investments
can bring about only incremental improvements.
Nonetheless, these bright spots lay
the groundwork for positive change.

For some funders, supporting equity
means working to influence federal policy
change. Many did so in the years leading up
to the passage of the ACA. Their grantmaking
elevated health reform as a critical issue and
helped keep it on national and state policy
agendas over the course of many years. They
also invested in outreach and enrollment activities—especially in low-income communities—and provided sustained support to
advocacy organizations and coalitions.

Post-ACA, many health funders continue
to support health system reform as one
strategy for eliminating health disparities.
For example, the Con Alma Health Foundation
is partnering with a national funder, the
W. K. Kellogg Foundation, to monitor the
implementation of the ACA in New Mexico,
with a special focus on low-income and rural
communities of color.

Other funders are taking a broader
view that addresses inequalities by moving
beyond health care and, in some cases,
outside the health sector. For example, the
California Endowment’s $1 billion, 10-year
Building Healthy Communities initiative
supports health equity, but it intentionally
does not fund direct health-care services.
Instead, its goal is to “change rules at the
local and state levels so that everyone is
valued and has access to the resources and opportunities essential for health: affordable
housing and fresh food, jobs that are
safe and pay fair wages, clean air, and the other
ingredients essential for a healthy life.”

Health funders who have partnered with
non-health organizations are an example of a
growing interest in working across sectors to
improve health equity. Many health funders
recognize that in low-income urban neighborhoods,
community development offers a vital
pathway for improving the underlying conditions
that shape health. By partnering with
community development organizations, they
have begun to invest in affordable housing,
community clinics, grocery stores, child care,
and other health-promoting initiatives.

One example of these partnerships is the
Healthy Futures Fund, an initiative of the
Local Initiatives Support Corporation,
Morgan Stanley, and the Kresge Foundation.
The fund supports development of federally
qualified health centers in underserved areas,
as well as affordable housing that incorporates
health programs for low-income residents.
If successful, these grantmaking strategies
could potentially lead to larger wins and could
be an opportunity for health philanthropy to
broaden its sphere of influence outside the
boundaries of the traditional health sector.

The Road Ahead

Because health equity is ultimately part
of the larger issue of social and economic
inequality, worsening economic inequality
in the United States threatens health
philanthropy’s ability to make meaningful
improvements. In recent months, the
Ford Foundation’s strategic shift to fighting
inequality has raised the question of the role
philanthropy can play in this arena.

Looking ahead, it is likely that there will
be increasing pressure for funders to recognize
the structural underpinnings of many
social problems—including health disparities—and to commit to transforming those
structural elements. This level of effort would
require focusing on root causes—in the case
of the Ford Foundation, these include the
distribution of wealth, education and opportunities
for young people, and justice based
on race, ethnicity, and gender—and the willingness
to take risks, invest for the long term,
and work across sectors. Such work would be
difficult and controversial, but because of its
ability to act independently and break new
ground, philanthropy may be particularly
suited for taking it on.

Faith Mitchell is president and CEO of Grantmakers
In Health. She was previously a senior program officer at the
Institute of Medicine, where she was responsible for the health
disparities portfolio, and a center director in the Division of
Social and Behavioral Sciences and Education of the National
Research Council.